Cricothyroidotomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Cricothyroidotomy (also called cricothyrotomy) 
is an emergency airway procedure that is done when 
other attempts to secure a definitive airway have 
failed. The situation may be trauma, upper airway 
neoplasm, severe infection compressing the upper 
airway, or excessive secretions or debris that cannot 
be cleared in a timely manner. Recall from Airway 
Management in Trauma that a definitive airway is a 
cuffed endotracheal tube, with the cuff inflated, in 
the trachea below the vocal cords.  
Cricothyroidotomy accomplishes this goal by 
accessing the airway through the cricothyroid 
membrane, immediately below the vocal cords. 
Therefore, it is possible to damage the vocal cords if 
this 
procedure 
is 
done 
carelessly. 
Also, 
cricothyroidotomy is contraindicated in small 
children for this same reason- the number most often 
quoted is 12 years of age or less.  
If you are lucky you will get to practice this 
procedure on a cadaver. Otherwise, the first time you 
see it done, you may be the one doing it. The 
situation is usually so extreme that the most 
experienced clinician, the one who has done a 
cricothyroidotomy before, should be the one to do it, 
for the patient’s sake. Multiple intubation attempts 
will have been made, resulting in upper airway 
edema; it may no longer be possible to ventilate the 
patient with a bag-valve mask and he may be 
desaturating or even becoming bradycardic from 
hypoxemia. He only has a few minutes left before 
brain hypoxia causes permanent damage.  
Try to anticipate this situation: when we see 
anesthesia personnel struggling in a difficult airway, 
we will quietly ask someone who’s not busy to have 
a #11 scalpel blade in the room, so that we can step 
in and perform a surgical airway rapidly. Most 
commonly this will be in a trauma situation, however 
it can also occur in the operating room during 
elective intubation of a patient with airway distortion 
due to tumor or infection.  
Cricothyroidotomy can be done with very 
few instruments if necessary: A #11 scalpel blade 
attached to a scalpel handle and an endotracheal tube 
are all that is needed. Select an endotracheal tube that 
is one size smaller than you would use to orally 
intubate the patient: In most adults, a 6.0mm 
endotracheal tube is an excellent choice. If available, 
a tracheostomy hook and a tracheostomy tube make 
things easier. 
The steps to cricothyroidotomy are: 
• Identify 
the 
tracheal 
cartilage 
and 
the 
cricothyroid membrane 
• Make a vertical incision and spread the skin and 
subcutaneous tissue 
• Make a horizontal incision through 
the 
cricothyroid membrane 
• Insert the tube and inflate the cuff 
 
Steps: 
1. Preoperative considerations are as discussed 
above. The patient will almost always be in 
extremis without another airway.  
2. Prepare the neck with betadine, chlorhexidine, or 
just an alcohol swab. This step can be omitted if 
none of these are immediately available. Personal 
protective equipment is highly encouraged, as the 
combination of a bleeding wound and the airway 
always results in wide dispersal of blood and 
secretions.  
3. Palpate the thyroid cartilage (“Adam’s apple”) 
and the smaller, less obvious cricoid cartilage 
about 1-2 cm caudal to it (below it). The 
cricothyroid 
membrane 
is 
between 
these 
structures, immediately inferior to the thyroid 
cartilage. 
 
The larynx seen anteriorly. The thyroid cartilage, sometimes 
called the “Adam’s Apple” (Black arrow) can easily be 
palpated: the cricothyroid membrane is just below this 
structure. It is incised transversely as shown by the Dotted line. 
The dark Red shape shows the relation of the thyroid gland to 
Cricothyroidotomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
the cricoid membrane. The hyoid bone (Red arrow) is a smaller 
bony structure, higher up in the neck adjacent to the mandible. 
It should not be confused for the thyroid cartilage, otherwise 
damage to the vocal cords could occur if the membrane below 
it is incised.  
 
 
Palpate the thyroid cartilage, the most prominent structure in 
the anterior midline neck. In this case, the neck is not 
hyperextended but the procedure can still be done. All of the 
photos in this chapter were taken from a cadaver dissection. 
 
4. Using a #11 or #15 blade, make a vertical 
incision extending from just above the thyroid 
cartilage to just below the cricoid cartilage, about 
3cm in length.  
 
Make a vertical incision from just above the thyroid cartilage 
to just below the cricoid cartilage. 
 
5. Spread the skin edges apart with your non-
dominant hand.  
 
Spread the skin horizontally, revealing the subcutaneous fat 
and the cricoid membrane. You can palpate the membrane at 
the center of the incision.  
 
6. Make a horizontal incision in the cricothyroid 
membrane. You should feel a “pop” as the blade 
passes through the membrane. After the “pop,” 
gently move the knife up and down in a sawing 
motion to cut the membrane. Be careful not to go 
too deep with the knife, you can potentially enter 
the esophagus here.  
 
Incise the cricothyroid membrane transversely with the scalpel, 
being careful not to cut too deeply and injure the esophagus.  
 
7. Turn the knife over and insert the handle into the 
incision you just made, then rotate it 90 degrees 
to stretch the membrane. Be careful not to injure 
yourself with the scalpel blade. 
Cricothyroidotomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Once the cricothyroid membrane has been incised, reverse the 
scalpel and insert the handle through the membrane incision in 
a horizontal configuration.  
 
 
Rotate the scalpel handle vertically, stretching the cricothyroid 
membrane incision. Be careful not to injure yourself with the 
scalpel blade.  
 
8. Insert an endotracheal tube into the trachea, 
directing the tip downwards. A stylet inside the 
tube helps direct it inferiorly into the trachea. If 
you have a tracheostomy hook, use it to retract 
the cricoid cartilage anteriorly. 
 
It can be difficult to insert the tube through the incision, 
especially if you do not hyperextend the neck, as in a trauma 
patient. Spread the skin with the thumb and index finger of your 
nondominant hand to expose the hole that you made in the 
cricothyroid membrane. The tube is malleable and may be 
difficult to pass through the small hole: a stylet can be used to 
make it stiffer.  
 
 
Two tracheostomy hooks.  
 
 
Pulling the cricoid cartilage downwards with the tracheostomy 
hook makes it much easier to insert the tube. Unfortunately, in 
an unexpected cricothyroidotomy, you usually won’t have a 
hook available. Alternatives include a bone hook from an 
Cricothyroidotomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
orthopedic set, or a skin hook from a plastic set. Be careful not 
to puncture the tube’s balloon when you withdraw the hook. 
 
9. Pass the tube no more than 4cm into the trachea 
and inflate the cuff. Confirm placement by 
auscultation and bear in mind that the tube may 
be inserted too far into one of the mainstem 
bronchi, usually on the right side. 
10. Secure the tube to the skin with two separate 
Nylon 
sutures, 
to 
prevent 
accidental 
dislodgement. 
 
 
A cricothyroidotomy done through a malignant thyroid tumor 
via a horizontal incision. The tube has been well secured, as the 
patient’s life depends on it not being removed. Despite the small 
size of the tube, the patient was maintained in the ICU, sedated, 
and the surgical team returned for tumor debulking and formal 
tracheostomy the next day.  
 
11. The 
conventional 
teaching 
is 
that 
cricothyroidotomy can remain in place for up to 
24 hours. This teaching is being questioned 
recently. If you think the patient can be extubated 
within a few days, it is probably better to leave 
this tube in place rather than subject him to a 
tracheostomy. 
Otherwise, 
convert 
to 
a 
tracheostomy 
under 
elective 
conditions. 
Alternatively, a skilled anesthetist, with or 
without video equipment may be able to pass an 
orotracheal tube after some time under more 
controlled conditions.  
12. Whenever the tube is removed, close the skin in 
an airtight manner. Make no attempt to repair the 
cricothyroid membrane, this is not necessary.  
 
Pitfalls 
• Misidentification of the thyroid cartilage, 
confusing some other bony structure in the neck 
for this one. This is surprisingly easy to do in an 
emergency situation, where you may be in a 
panic.  
• Incising too deep and damaging the esophagus: 
maintain control of the knife and only cut the 
membrane: you will feel its resistance as you cut.  
• Difficulty in passing the tube: this may be 
because you did not incise the cricothyroid 
membrane enough, you did not dilate it far 
enough with the scalpel handle, or the tube is not 
stiff enough to pass into the space. Try a smaller 
tube, or try holding it closer to the tip, or insert a 
stylet. A tracheostomy tube, stiffer and with a 
built-in curve, will be easier to insert than a 
floppy straight endotracheal tube.  
• Damage to the balloon by the sharp tracheostomy 
hook as it is being withdrawn 
• Injury to the vocal cords, which are immediately 
above the cricothyroid membrane.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
October 2023 
